My First Patients - All 54 of Them

After we finished our Biochemistry block, we had a nice 4 day break before heading into our 'Clinical Week' last week. The medical school assigned us all to different clinics across North Carolina, and in different primary care practices (Family Medicine, Internal Medicine, Pediatrics, or OB/Gyn). And as fate would have it, I was assigned to the specialty that would have been my absolute last choice - Pediatrics. Now, it's not that I hate kids, but I just wish they could act more like adults sometimes. Kids can be annoying, bratty, unwilling to cooperate, and are more likely to be disrespectful and hard to manage. But surprisingly, I came across none of these characteristics with the patients I saw last week. My theory is that sick kids are so drained of energy due to their illness/injury that they just don't have it in them to be annoying or rude anymore. So now instead of disliking all kids - I have a new found appreciation for sick kids - they are absolutely lovely (especially the ones with high fevers - it makes them so loopy and thus that much more entertaining).

A New Meaning to the Term "Small Town":

Now a bunch of my medical school classmates were assigned to practices in small towns hours and hours away from Chapel Hill - in the mountains or by the beach, but for me: I got to return to my very small hometown of Knightdale, North Carolina - located just east of Raleigh. (If you drive east from Raleigh on 64 towards Wendell, Zebulon, or Greenville - you will very literally drive through the entire town of Knightdale - in less than 6 minutes). My family and I have been living in Knightdale for 9 years now and I thought I knew all there was to know about this 2.7-square mile town. But interacting with the locals and researching some of the demographics of this area helped me learn much more about this small community. The clinic I was assigned to just happens to be the same pediatric clinic where my little brother goes for his checkups. It's located literally right behind the residential housing community where we live - a 5 minute drive from my house. Very convenient!

The First of Many to Come:

The pediatrician I was assigned to looked like a slightly younger version of Santa Claus (one whose hair hadn't entirely turned white) - and what better figure to be dealing with children, right? I shadowed him for the very first patient we saw, and then as we headed to the next exam room, he smiled at me and said, "How about you get the history on this next patient?" He must have picked up on the skepticism on my face to which he responded with a comforting, "It's okay. You can do it!" And just like that I was off to see my first real patient all by myself. I knocked, walked into the room and let my ICM skills take over. (Throughout the past couple months, a 2-year long course called Intro to Clinical Medicine had been preparing us for how to take great patient histories and do a solid patient interview). Aaahhh...what a moment. Definitely a huge first. Whatever nerves I felt before walking into that first room however, quickly subsided by about my 3rd patient interview. I started figuring out the algorithm - which questions to ask for certain symptoms and I started to understand which information was relevant for presenting to the doctor once I got back from the interview. And whoooshhh - just like that I'd done 54 patient interviews in just 4 days.

Patient Ailments:

It wasn't long before I started seeing a trend in the patient chief complaints. Colds, flu, asthma-induced coughing and wheezing, Strep, and seasonal allergies - were definitely leading the pack. And although I expected this, there wasn't a dull moment as the doctor helped me understand the process of differential diagnoses. Similar symptoms could be due to very different underlying issues - and knowing the right kinds of questions to ask was key. And throw in another wrench: a lot of times since children couldn't verbalize their complaints, the parents would have to speak for them. And often times while parents were certain their child had a minor cold, the patient history and exam would reveal that the kids had severe ear infections, despite the fact that they never complained of their ears hurting. This was an interesting dynamic - since I had to learn to interview the kids, their parents, sometimes their siblings, and in cases of contradictions, I had to decide whose word was most reliable.

The Super-Interesting Patient Cases:

Aside from the common problems, there were also some rare cases that were just totally awesome! Even amongst this group, there were some that are still fairly common problems: autistic patients (both very low-functioning and very high-functioning (the high-functioning patient was a 2nd year student in college and was feeling anxiety because he just didn't feel like he fit in - despite how hard he tried - hearing him express his problems just broke my heart), as well as a mosaic chromosome 8 autistic patient), poison ivy rashes, knee/shoulder injuries, ingrown toenails (the doctor actually taught me how to remove the ingrown toenails - so much blood..LOVED IT!), ringworm, concussion, a bunch of infants with gastric reflux, and a bipolar patient.
And then there were conditions that were super rare/incredibly interesting: Hashimoto thyroid disease (leading to delayed onset of puberty and short stature), a little boy with Fifth's disease (bumps and rashes all over his face), a little girl with a thyroid-duct cyst which had bled into itself (the doctor referred her to a surgeon to get it removed), an infant and his breast-feeding mom both with Thrush syndrome, a toddler with pica - meaning she licked things that really shouldn't be licked (like the floor of grocery stores), infants with umbilical hernias (maybe this is more common than I thought - but definitely towards the top of my list of interesting cases), a 2-year old with a yeast infection, and a patient with Ornithine Transcarbamylase Deficiency (OTCD - a genetic metabolic disorder only occurring in 1/80,000 births - we just learned about this in Biochem block!!) This list covers every single patient I saw last week.

Overall, this was a great experience - much more exciting than I originally thought it would be - and I'm looking forward to the next Clinical Week (which will be in the Spring semester - by which point we will have learned more human anatomy and know how to do physical exams!!)

Up next is Anatomy block! We start dissecting cadavers on Tuesday and naturally that will mean another post about how it feels to cut into the flesh of a once-living human being - another major first for me.

End of First Block!

I last posted about my first lecture of medical school and just like that - 2 months have passed and we've just finished our first block - Molecules to Cells, which is just a fancier name for Biochemistry. (Side note: Any pre-medders that still have time - it would be a valuable investment of your time to take at least one biochem course in undergrad - not necessary but definitely helpful). Along with Biochem, we also had some Molecular Bio and Cell Bio, sprinkled with Genetics. The material was sometimes difficult to digest, but overall it was a superb block.

Instead of going into the details of the block, I just want to write about my reflections of medical school - now that I've had some time to get used to the new schedule. So here it is: I absolutely love UNC Med. I love it. And no, I'm not uber-stressed all the time, and no I'm not always busy studying. I actually have quite a fair amount of free time - which is surprising but incredible at the same time. Other things I love:
I love being back in school.
I love being back at UNC.
I love that our classes usually end by noon.
I love that all the classes are recorded so I don't necessarily have to go to all of my classes. (No mandatory attendance).
I love that I can study on my own time - without going to classes and still do well on my exams.
I love that everything is pass/fail first year.
I love being tested on material every 2 weeks (Every other Monday is our exam day). So everything we study in each 2-week chunk of time is tested on one and only one exam - we don't have different exams for different topics/lectures.
I love ICM - Intro to Clinical Medicine - a weekly class that teaches us physician skills like interviewing patients, doing patient exams. Even without having a full set of medical knowledge, we're still learning how to ask the right kinds of questions to solve problems and treat patients.
I love small group activities - where we're given cases to solve applying the freshly-learned material from class that week.
I love our weekly Medicine and Society discussion course partly because it's a nice break from the science courses.

I can go on and on. I am just so excited and blessed to be where I am right now. Medical school is everything I had hoped and so much more. Days like today when I don't have much to do (we're out on Fall Break) - these are the days that make me realize how much I love and miss studying. Okay so sometimes I don't absolutely love studying, but I like knowing that the biochemical pathways that I'm memorizing, the diseases I'm studying about, the terms I'm trying to remember - are all part of the journey that is ultimately going to allow me to become a full-fledged doctor (God willing).

When I found out last year - almost exactly a year ago (10/15/09) - that I had gotten into medical school I was naturally ecstatic. I was told by various medical students and doctors that the best part of this process is from the day you find out to the the day you start medical school. I don't know what their experiences were like, but I absolutely disagree. If anything, my experiences have gotten so much better since classes started. If anyone is considering medical school, and is feeling overwhelmed by the anticipation of stressed time-management or concerned that your soul will die in school - this is not the case at all. When you're doing something you love, you find a way to make everything work.

And now as Biochem comes to a close, we will be spending next week working in a clinic for our Clinical Week preceptorship (stay tuned for updates from that). After that, we start Anatomy block! And I couldn't be more excited. I have been waiting such a long time for Anatomy - and it's finally right around the corner. I'm looking forward to cadaver dissections (as morbid as that sounds) and learning more about the human body. And I hope to embrace each and every day of medical school with this same eagerness and excitement that has engulfed me as of late.

The First Lecture of Medical School

My first lecture of medical school started out with this fascinating poem. I couldn't help but share:

Heredity I am the family face; Flesh perishes, I live on, Projecting trait and trace Through time to times anon, And leaping from place to place Over oblivion. The years-heired feature that can In curve and voice and eye Despise the human span Of durance -- that is I; The eternal thing in man, That heeds no call to die -Thomas Harding

The Price of Immortality - Story of HeLa Cells

I remembered very little from undergrad Biology courses about HeLa cells when I started reading the UNC School of Med's summer reading: The Immortal Life of Henrietta Lacks, but upon finishing the book, there are certain mind-blowing concepts that I just have to jot down. First of all, a quick summary of the story: In 1951, a 31-year old African-American lady by the name of Henrietta Lacks went to Johns Hopkins Hospital for what she felt was a 'knot' in her stomach. She was diagnosed with cervical cancer, and doctors began treatment for her cancer. The story gets interesting though, because when doctors saw the incredible rate at which her tumor had spread, they took a sample of her tumor without consent. The cells from the sample were cultured and much to the surprise of the researchers, these cells kept on growing and reproducing, when provided with the proper cell survival conditions. Henrietta Lacks died within a few months after being diagnosed, while her cancer cells continued to thrive and achieved 'immortality'.

Now for decades, scientists and researchers were using the HeLa cells (abbreviated for the patients first and last names) in cancer research, to help develop the polio vaccine, for AIDS research, to see the impact of zero-gravity space conditions on human cells, etc. .. while Henrietta Lacks's family had no clue a part of her was still alive. When her children found out, they were naturally outraged on a number of levels: a) that their mother's cells had been taken without consent, b) that companies were profitting from the research done with these cells while they themselves were barely making ends meet, c) that no one had even told them for years that Henrietta's cells were being used, and so on. The book went into detail about the family, their reactions, and their desire to inform others about their mother - a very interesting aspect to the HeLa story that most Biology students don't get to see.

However, what absolutely blew me away was the reason for the HeLa cell immortality. Now, cancer cells are basically cells that continue dividing when they should have stopped. Whether grown in culture or in the human body, normal human cells are preprogrammed to die after a certain number of cell divisions. According to the Hayflick Limit, that number is 50 for most cells. After 50 cell divisions, normal cells usually undergo preprogrammed cell death (apoptosis). Because of this limitation on cell division, normal non-cancerous human cells never survived on culture when scientists tried to use them to grow an immortal cell line.

So how does a normal cell become cancerous? When a virus or genetic mutation transforms the cell, it can become immortal. In the case of Henrietta Lacks, she had been infected by a very deadly strain of the Human Papilloma Virus (HPV), HPV-18. This virus inserted its DNA into Henrietta's 11th chromosome and turned off her p53 tumor suppressor gene.

Now for the cancer mechanism: Everytime a normal cell divides, there is a chain of DNA at the end of each chromosome, called a telomere, that is shortened a little per division. When they've divided, oh say 50 times, the telomere part has almost disappeared entirely, so the cell stops dividing and dies. Cancer cells have an enzyme called telomerase that keep on rebuilding the telomeres. So the telomeres are never shortened, and the cell doesn't undergo cell death. "This explained the mechanics of HeLa's immortality: telomerase constantly rewound the ticking clock at the end of Henrietta's chromosomes so they never grew old and they never died" (Skloot, 209).

Okay, so this is the thought I can't get out of my head: so as we age, our normal cells undergo aging, the telomeres on the ends of our chromosomes get shortened, and soon the cells die, which eventually leads to dysfunction in our different body systems and thus to our death. Telomerase on the other hand, prevents telomeres from shortening. So, this is such a long shot, but could it be possible to prolong human life if we discovered a way to synchronize the extension of telomeres on all our chroosomes in our cells? Aaahh..mind-blowing, right? Several decades ago, even the thought of cell immortality was unthinkable, but HeLa has proven it possible. Could it be that further research can provide insight into human immortality? But what a fine line, right? Extend telomeres just enough on just the right cells - live longer. But if all the wrong cells start living longer than they're supposed to - boom, it's cancer. The very HeLa cells that proved immortal were the ones that drastically shortened Henrietta Lacks's life. On one side you have rapidly-growing cancer, on the other - immortality.

Signs of New Beginnings

After what has felt like an eternity of waiting, in just 2 short weeks, I will finally be starting medical school at UNC-Chapel Hill. And my good friend Nawsheen suggested that I absolutely have to start blogging about the experiences to ensue.

So I took her advice and how's this for a sign: as I was creating this new blog, it prompted me to write in the random word that came up on screen and that word was 'healin'. And one thing led to another, and I couldn't help but set the words 'TarHealer' in the URL. Haha..clever, I know.

Anyway, as excited as I am to embark on this long-awaited journey, I cannot believe how much has happened over the past few months and it saddens me that so much has to come to an end. (End of undergrad, my best friend getting married and moving hundreds of miles away, deciding to move into an apartment closer to campus and thus further from my family). Nonetheless, I am anxiously awaiting my first day of medical school and all the excitement and even obstacles that it will bring.